Disabilty_Floyd 014 APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
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,� � ; DEDUCTION FROM ASSESSED VALUATION
�� <•.!1 State Form 43710(R13/1-20) Gibson 021 2020
�` Prescribed by the Department of Local Government Finance
File Mark
Information contained in this document Is CONFIDENTIAL pursuant to IC 6-1,1-.5-
INSTRUCTIONS: To be filed in person or by mail with the County Auditor of the c.• r ere the property is located.
Filing Date: Form must be completed and signed by December 31 and filed or postmarked by the following January 5 of the calendar year in which the
property taxes are first due and payable. / f
See reverse side for additional instructions and qualifications. ?h . '12 -(0b -3 4 s3
} Name of applicant(owner or contract buyer)
Mark S Floyd
Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? If owned wi d-= ;one other than spouse,
lndi
0Yes No y
If name on record is different than that of applicant,indicate below:
Name of contract seller
p�T�Address of contract seller(number and street,city,state,and ZIP code) 4uo0"
tttG erty in question:
8 G� lZi Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Is applicant blind as defined in IC 12-7-2-21(1)? Is applicant disabled and unable to engage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
❑Yes 0 No 0 Yes ❑ No
Is the property used and occupied primarily for his/her residence? Does the applicants taxable gross income for the preceding calendar year
exceed$17,000?
( Yes No ❑Yes ® No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
021 26-17-17-300-004.932-021
I/We certify un r penalty of perjury that the above and foregoing information is true and correct.
Signature o f nt Address of applicant (number and street,city,state,and ZIP code)
7005 S 1100 W, O'ville IN 47665
Sig t e of authorized representati Address of authorized representative (number and street,city,state,and ZIP code)
1 RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name of applicant Date filed th,day,year)
Mark S Floyd 5
Name of contract seller n
O`/
Taxing district
G/B e020
021 �.v co
14/
Key number/legal description •vT,ai
40,26-17-17-300-004.932-021 %4,
Signatu A‘...uv\.„1/4.1.of County Auditor Date signed(month,day,year)